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Joseph Sirven

Medical Errors in Epilepsy — Redemption

Joseph I. Sirven, M.D.
Editor-in-Chief, Epilepsy.com/Professionals

Recently I had the opportunity of attending an institutional Medical Grand Rounds on a rather provocative topic. The lecture entitled” Medical Redemption” consisted primarily of physicians telling stories of medical errors that they had committed in the presence of patients who had been the subject of these errors. The point was to examine the issue of medical errors from two vantage points; physician and patient. If I had been a malpractice attorney, I would be in a state of disbelief and shock to witness an open discussion of one of the most emotionally fraught and legally complicated topics that can confront a medical professional. As I listened to their stories, I was struck by a few observations. Physicians who committed the errors were riddled with guilt out of proportion to the patients’ expressions of anger over the error. Patients seemed to be forgiving even when the consequences of the error were quite serious and long-lasting. Admitting the error appeared to relieve the patient and physician from the burden of anger and guilt respectively. It seemed that the old dictum that “It isn’t the crime that creates problems, but it’s the cover up” seemed to be a reality in the field of medical errors at least from my perspective as an attendee.

This led me to wonder about my own medical errors over time in the care of patients with epilepsy. I have personally never seen any literature or been privy to nonconfidential conversations of specific instances of medical errors as it pertains to epilepsy management. Attorneys often counsel that admitting a mistake publicly has legal implications and therefore the topic is somewhat taboo. However, we are certain that it occurs. Attendance at any hospital morbidity and mortality conference can confirm it. I too can profess to having committed a medical error which I have had to address with a patient and I have been personally forgiven by the patient. However, I was lucky as there were no long lasting untoward effects as the result of the error. Nevertheless, errors have consequences and oftentimes the patient will look for their care elsewhere after such an admission.

So how often do medical errors occur in the US? In November 1999, the Institute of Medicine issued a report entitled “To Err is Human; Building a Safer Health System” addressed this issue and the statistics were staggering. The authors found that as many as 44,000 to 98,000 people died in hospitals every year as a result of medical errors. By using the conservative estimate of the extent of the problem, medical errors would actually rank as the eighth leading cause of death in the United States, higher than motor vehicle accidents, breast cancer, and HIV. 7,000 people a year are estimated to die from medical errors. Errors are not restricted to hospitals but they occur in any healthcare settings such as physician offices, nursing homes, pharmacies, urgent care centers and care delivered in the home. The costs of these errors are in the billions of dollars.

To date there are no estimates that delineate the extent or cost of medical errors in the field of epilepsy. However, one can make an educated guess based on several papers that have courageously addressed the allied topic of complications as a result of specialized epilepsy care. Most notable are those from Noe and colleagues, reporting 21% of epilepsy monitoring units had some type of adverse event and from Hamer and colleagues, reporting the complication rate from invasive EEG monitoring. However these are complications that may be expected and would not be considered an error based on the definitions from the Institute of Medicine. Therefore the extent of the problem in epilepsy is not known.

So how should physicians address medical errors when caring for patients with epilepsy? If one accidentally overdoses a patient with extra anti-epileptic medication which results in toxicity or an unusual complication, does the physician or healthcare professional take the blame? Does one call the patient? How will the patient/physician relationship be altered as a result of this admission and can it ever really recover? The answers to these questions are not known, but intuitively honesty appears to be the best policy with regards to one’s admission of errors when they occur. More study is clearly needed for the best approach.

So as I sat in the audience anonymously in a cavernous auditorium listening to patient and physician stories, I was struck by how fragile the patient/physician relationship really is. The same trust issues that typify a partnership, a marriage, a friendship are the same ones involved in the relationship between physician and patient. One has to be honest, open and caring with regards to how information is presented. Communication is essential and yes legal counsel is sometimes needed. I suspect the issue of medical errors will remain an unspoken issue but it is important to understand how difficult the issue is for both patient and physician.

References:

  1. Institute of Medicine. To err is Human, Building a safer Healthcare system. 1999. National Academy Press.
    http://books.nap.edu/html/to_err_is_human/reportbrief.pdf
    Accessed September 29. 2009.
  2. Noe K, Drazkowski J. Safety of Long-Term Monitoring for Evaluation of Epilepsy. Mayo Clinic Proceedings 2009:84(6): 495-500.
  3. Hamer H, Morris H, Mascha E, Karafa M, Bingaman W, Bej R and colleagues Complications of invasive video-EEG monitoring with subdural grid electrodes. Neurology 2002; 58; 97-103

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New on Epilepsy.com Professionals During October

During the month of October on epilepsy.com we will continue highlighting new topics and issues that arise from the epilepsy community. We have three “Hallway Conversations” that we will be highlighting this month.

Our first program addresses the launch of the My Seizure Diary. Robert Fisher, MD, PhD the diary’s authors will explain and discuss the utility of this innovative new tool which could revolutionize the clinic visit.

Our second program is devoted to the topic of “Non-epileptic Events and Their Management”. We have two neuropsychologists, Dr. Kristin Kirlin and Dr. Dona Locke, who will be discussing the psychological management of this condition and what clinical advice can they impart to neurologists and epilepsy physicians in order to better the care of the patient with non-epileptic events.

We also will be highlighting the issue of epilepsy monitoring. Epilepsy monitoring is a cornerstone in the evaluation of patients with seizures and is often one met with concern and anxiety on the part of the patient when they are being admitted to the video monitoring unit. Given that patients do not want to have their seizures, it seems somewhat contradictory that one is being admitted to a hospital in order to suffer the event that seems to rob patients of their independence and their quality of life. As such we want to examine the epilepsy monitoring unit environment, dispel any myths and present why it is done and some of the issues that the patients and professionals can understand about epilepsy monitoring as a whole. During a special “Hallway Conversations” Dr. Korwyn Williams from Phoenix Children’s Hospital and Dr. Joseph Drazkowski discuss the topic of epilepsy monitoring in both adults and children.

In addition we continue to update all of our other topic areas on the website and we hope that you will enjoy the various content features in epilepsy.com.

Joseph Sirven, M.D.


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